OBJECTIVE: The skepticism regarding the
existence of dissociativeidentity disorder as well as the abuse that engenders it persistsfor lack
of objective documentation. This is doubly so for thedisorder in murderers because of issues of suspected malingering.This article presents objective verification of both dissociativesymptoms and severe abuse during childhood
in a series of adultmurderers with dissociative identity disorder. METHOD: Thisstudy consisted
of a review of the clinical records of 11 menand one woman with DSM-IV-defined dissociative identity disorderwho had committed murder. Data were gathered from medical, psychiatric,social service, school, military,
and prison records and fromrecords of interviews with subjects' family members and others.Handwriting
samples were also examined. Data were analyzed qualitatively.RESULTS: Signs and symptoms of dissociative
identity disorderin childhood and adulthood were corroborated independently andfrom several sources
in all 12 cases; objective evidence ofsevere abuse was obtained in 11 cases. The subjects had amnesiafor
most of the abuse and underreported it. Marked changes inwriting style and/or signatures were documented in 10
cases.CONCLUSIONS: This study establishes, once and for all, the linkagebetween early severe
abuse and dissociative identity disorder.Further, the data demonstrate that the disorder can be distinguishedfrom malingering and from other disorders. The study shows thatit is possible, with great effort, to obtain
objective evidenceof both the symptoms of dissociative identity disorder and theabuse that engenders
it. (Am J Psychiatry 1997; 154:1703–1710)

INTRODUCTION

The diagnosis of dissociative identity disorder (formerly calledmultiple
personality disorder) is usually not made until adulthood(1), long after the extreme maltreatment thought to engenderthe condition has
passed. Therefore, although there is a consensusthat the most common cause of the disorder is early, ongoing,extreme physical and/or sexual abuse (2–6), accounts ofsuch abuse are usually provided retrospectively by the patientand lack objective verification. As Putnam (1) said, "In mostreports, including the NIMH survey, there is no outside
verificationthat any trauma actively occurred."

Coons (7) recently attempted to verify abuse histories in agroup of 19 children and
adolescents through interviews withfamilies and "collateral reports from numerous sources." Theextent
to which abuse was documented in each case was unclear.Because neither the symptoms nor the abuse engendering
themhave ever been documented objectively in a group of dissociativeidentity disorder patients of
any kind (children, adolescents,adults, or murderers), both the diagnosis and its etiology inchildhood
maltreatment have met with criticism ranging fromskepticism to scorn (8–15).

The diagnosis in felons is doubly suspect. The prospect of facingthe
consequences of a serious offense invites malingering (16,17). Dinwiddie and colleagues (18) asserted that the disorder,especially in forensic cases, could not be distinguished
frommalingering. Orne and colleagues (19) suggested that the mostobjective means of making the diagnosis in forensic
cases wasthrough interviews with family members and others who had observedthe characteristic behavioral
changes in the individual beforehe or she had committed a particular offense. To date, however,there
have been no such systematic studies of groups of felonswith dissociative identity disorder or, for that matter,
ofany other series of adult patients with the disorder. Carlisle(20) described 13 murderers suffering from multiple personalitydisorder but provided few objective data to support
the diagnosisor its etiology. Coons (21) collected information on a groupof 18 murderers alleged to have suffered from multiple personalitydisorder;
his data were gleaned in great measure from newspaperaccounts and legal decisions. For lack of objective documentationof symptoms or abuse, in most instances the diagnosis was disbelieved.

= Given the dearth of objective documentation of dissociativesymptoms
and the antecedent abuse that engenders dissociativeidentity disorder, we welcomed the opportunity to present
objectivedata on dissociation and abuse in 12 murderers suffering fromthe disorder. As will be discussed,
we believe that our findingsare also relevant to cases of the disorder in adults who havenot committed
violent crimes.

METHOD

During a 13-year period in the 1980s and 1990s, the first author(D.O.L.)
had the opportunity to do psychiatric evaluations ofapproximately 150 murderers. Of these murderers, 29 were subjectsin a study of death row inmates. The majority of the rest wereevaluated at the request of individual defense
attorneys. Severalothers were evaluated at the request of the court, of prosecutors,or of family members.
Of these murderers, 14 met the DSM-IVcriteria for dissociative identity disorder. We were able toobtain
objective documentation of both child abuse and long-standingdissociative signs and symptoms in 11 of these 14
individualsand of early dissociative signs and symptoms in a 12th. Thisreport focuses on the 12 murderers
with dissociative identitydisorder for whom objective, confirmatory data on child abuseand/or long-standing
dissociative symptoms could be verified.There were 11 men and one woman. Their ages at the time of theiroffenses averaged 28 years (range=15–44). Eight were whiteand four were black.

The subjects' psychiatric, neurologic, medical, social service,welfare,
school, probation, police, prison, and military recordswere reviewed, and in eight cases social service, medical,
psychiatric,military, court, or police records pertaining to parents werealso reviewed. Any evidence
of abuse, neglect, and/or dissociativesigns and symptoms was noted and tabulated.

All 12 subjects had been evaluated psychiatrically by the firstauthor
(D.O.L.), a board-certified psychiatrist. Nine had beenexamined neurologically by one of the authors (J.H.P.),
a board-certifiedneurologist; a 10th was examined by another board-certifiedneurologist. An 11th,
at age 2, had been evaluated by a neurologist,at which time an EEG was performed. The psychiatric and neurologicreports of these evaluations were reviewed. The nature of thepsychiatric and neurologic evaluations and
the criteria forspecific signs and symptoms have been described elsewhere (22–25).During these psychiatric evaluations, dissociative phenomenawere explored in detail and included questions about trances,time loss, fugues, amnesias, imaginary companions,
rapid moodshifts, auditory/visual hallucinations, fluctuations in skills,being blamed for disavowed
acts, sounding/acting like a differentperson, and using different names/signatures/handwriting. Recordsof
these neuropsychiatric evaluations and of any previous evaluationswere reviewed for the presence or absence of
the above-mentionedsigns and symptoms. Handwriting samples (e.g., old journals,letters) were also
examined. These written materials were producedbefore the subjects' psychiatric evaluations and thus were notinfluenced by the examiner. In all cases, affidavits, testimony,and/or reports of interviews with family
members, friends, neighbors,childhood acquaintances, teachers, probation officers, police,and clergy
were reviewed for mention of the signs and symptomsand for any indications of abuse and neglect.

At the time of publication of this article, clinical data regardingsymptoms and abuse histories were in the public domain (i.e.,in trial transcripts, exhibits, appeals briefs,
newspaper articles,and books); hence, informed consent to tabulate data was notnecessary. Nevertheless,
out of respect for the privacy of thesubjects and their families, we have not identified the subjectsby
name.

RESULTS

Signs and Symptoms of Dissociative Identity DisorderTable 1 presents the subjects' dissociative symptoms in childhoodand adulthood
and the corroborative documentation. Among themost common symptoms and signs were trances, amnesias for circumscribedperiods of time and/or particular behaviors, changes in voiceand demeanor, and auditory hallucinations.

As can be seen in table 1, the amounts of information availableon the subjects' childhoods varied.
We were able to obtain objectiveevidence that during childhood, eight of the 12 subjects hadtrances
and amnesias, nine had experienced auditory hallucinations,and 10 had vivid and long-standing imaginary companions
whoseemed to be precursors of their alternate personality states.

Ten subjects experienced trance-like states in adulthood thatwere
also observed by others. Two described their ability toremove themselves from situations as "astral projection."
Othersdescribed their trance-like states as blanking out, spacingout, or transporting themselves to
imaginary places in theirheads. Seven reported being able to block out physical pain.

All 12 subjects, as adults, had impaired memory for both violentand
nonviolent behaviors. For example, subject 5 pulled outhis own toenails at night and, in the morning, did not
knowhow this had happened. Subjects 4, 5, and 11, all of whom hadfemale alternate personalities, found
women's clothing in theirpossession and did not know how it got there. Subject 4, attrial, insisted
that the bloodstained suit he had been wearingat the time of his arrest belonged to someone else because itwas too big to be his.

All 12 subjects were described by others as having voice changesand/or
marked changes of demeanor. For example, three peoplereported that subject 9, the only woman in the study group,periodically sounded like an aggressive male, and male subjects4 and 11 at times reportedly sounded like
women. Subjects 5and 6 were noted to have alternate personality states with differentvisual acuities,
and the lawyers for subject 4 reported thathe did not recognize his own voice on tape-recorded police interviewsand insisted it was the voice of someone else. All 12 subjectshad used different names at different times,
not in the contextof avoiding arrest or responsibility. Writing samples obtainedfrom 10 subjects revealed
markedly different handwritings. Figures 1,2, 3, and 4 are examples of the different signatures andhandwritings of three of
these 10 subjects.

All 12 subjects had histories of experiencing
auditory hallucinationsthat, during psychiatric evaluation, were recognized by theexaminer as being
voices of alternate personalities. Seven experiencedsevere headaches when they heard arguments in their heads
amongalternate personalities. Subject 1 pulled out his own teethin an unsuccessful effort to cure
his excruciating headaches.

In all cases, examiners were able to speak with at least onealternate
personality. The subjects averaged three to four personalitystates (the range was one to seven). These figures
may be underestimatesbecause of the limited time available for evaluations. Ninesubjects (including
our only female subject) had violent malealternate personalities, most of whom said they "took the pain."Six male subjects had older female alternate personalities whosefunctions were caretaking, comforting, and
protecting. Of note,five subjects had alternate personalities who were embodimentsof parents or relatives;
two had abusive father personalities,one had an abusive mother personality, one had a powerful auntpersonality,
and one had a sister personality. The nature andfunction of these alternate personalities and their relevanceto the crimes committed will be described in a subsequent paper.

Table 1 lists the sources of information confirming evidenceof dissociative
identity disorder in each subject. As can beseen, documentation regarding subjects' dramatic changes ofvoice
and/or demeanor came not just from family members butalso from police records, notes of a legal assistant, observationsof a jail guard, observations of a prosecution psychiatrist,and subjects' co-workers, roommates, acquaintances,
and friends.As mentioned, objective documentation of personality changesin the form of different handwriting
and signatures could alsobe found in the journals, letters, and documents of 10 subjects.

The Nature of Maltreatment in ChildhoodBecause the histories of abuse of both patients with dissociativeidentity
disorder and murder suspects are often questioned,we call special attention to table 2, which presents objectivedocumentation of the nature and extent of
physical and sexualabuse of 11 of our 12 subjects. The term "abuse" does not dojustice to the quality
of maltreatment these individuals endured.A more accurate term would be "torture." For example, subject4
was deliberately set on fire by his parents. Subject 6 wasused in child pornography by stepfathers and was deeply
scarredfrom anus to mid-buttock from having been made to sit on a stoveburner. At 3 years of age,
subject 2 had his penis scalded and"circumcised" by his father. Subject 5 was tied down by hisstepmother,
given enemas allegedly containing blood, and, tostanch the blood, had tampons inserted into his rectum, thussimulating menstruation. This subject was removed from one fosterfamily because he had been caught molesting
other children andwearing girls' underwear and sanitary napkins.

We were surprised to find that in their usual personality states,most subjects denied or minimized childhood maltreatment. Fourof them, for whom documentation of extraordinary
abuse was discovered,totally denied any physical or sexual abuse. Seven others whohad been severely
physically and/or sexually abused had butfragmentary memories of the abuse. None attempted to use historiesof abuse to enlist the sympathy of jurors or to excuse theirviolent acts. Since in their usual personality
states most ofthe subjects had no idea of the kinds of maltreatment they hadsustained, they could
not use histories of abuse to manipulateclinicians or anyone else.

Histories of maltreatment were obtained primarily from old records,accounts provided by first-degree relatives, and the reminiscencesof childhood friends. For example, subject
3 had no recollectionof his incestuous relationship with his mother; informationregarding incest was
gleaned from the social service recordsof his brother. Similarly, subject 6 knew nothing of the sexualabuse
sustained at the hands of his grandparents. The affidavitof a cousin who lived with him during childhood—a
documentdiscovered by one of the authors (D.O.L.) after the subjecthad been executed—revealed
that his grandmother had dressedhim as a girl and given him to his grandfather to be used forsexual
gratification.

Before evaluation none of the subjects was aware that he orshe
suffered from dissociative identity disorder, and most remainedignorant of their condition after their psychiatric
evaluations.Even after some were told of their condition, they tended todisbelieve it. For example,
when subject 4 learned of his diagnosisat a court hearing, his response was, "I think you're full ofshit."
Of note, in this case, because of his dramatically changingdemeanor during incarceration, the subject's fellow
prisonershad made the diagnosis of multiple personality disorder yearsbefore the psychiatrist ever
saw him.

DISCUSSION

Our ability to interview subjects' family members and friends,our
access to their past psychiatric, social, and educationalrecords, and our access to their personal letters and
diariesenabled us to document evidence of long-standing dissociativesymptoms in all 12 of our subjects
and to obtain objective evidenceof extreme abuse of 11 of them. Rarely, if ever, do psychiatristshave
the opportunity to obtain this quantity and quality ofconfirmatory data about adults with dissociative identity
disorder.It was only because of the time-consuming investigations conductedin the course of the legal
representation of these murderersthat we could amass these kinds of data.

Contrary to Dinwiddie and colleagues (18), we have demonstratedthat dissociative identity disorder can be differentiated
frommalingering and other disorders. The evidence of strikinglydifferent handwriting styles antedating
the murders in question,plus the documentation of amnesias and of changes in voice,demeanor, and appearance
observed by family members and othersbefore our subjects' crimes, settles once and for all the issueof malingering in these cases. To have malingered, our subjectswould have to have planned their murders
long in advance andfeigned their early symptoms in anticipation of some day committinga violent crime,
a highly unlikely scenario. In short, withadequate data, it is possible to distinguish dissociation frommalingering and from other disorders. For example, althoughdissociative identity disorder shares certain
symptoms withschizophrenia, bipolar disorder, and other syndromes, none ofthese other disorders is
characterized by the voice, demeanor,and handwriting changes and amnesias characteristic of dissociativeidentity disorder, as documented in our study group.

The question remains: to what extent are our 12 murderers withdissociative
identity disorder representative of other adultswith the disorder? After all, most patients with the disorderdo not commit murder. On the other hand, most patients withthe disorder do have aggressive, protector personality
states(1, 5). However, relatively few commit violent crimes, reflecting,at least in part,
the fact that most recognized cases of dissociativeidentity disorder occur in women (1, 26, 27), and women as agroup are far less violent than men (28). Whereas Loewensteinand Putnam (26) reported that similar percentages of men andwomen among their subjects
with multiple personality disorderhad "homicidal alters" (35% versus 32%), 19% of the men andonly
7% of the women reported actually having committed murder.In our own clinical experience, we found that among
the maleoutpatients seeking treatment for dissociative identity disorderat our clinic, a substantial
percentage (64%) had demonstratedrageful behaviors that came just short of homicide. In fact,one patient
reported spending time in a reformatory after committingmurder, and two others had been arrested for attempted
murder.A much smaller percentage of the women in our clinic group (9%)were similarly aggressive. One
had attempted to shoot her adultson, and another had tried to push her father in front of acar.

The majority of the males with dissociative identity disorderthat
we have seen have not been clinic outpatients but, rather,have been examined in prisons, where they were incarceratedfor violent crimes. On the basis of our clinical experience,we suspect that the diagnosis of dissociative
identity disorderis overlooked in males more often than it is in females becausethe violent behaviors
of the protector alternate personalitystates of men go unrecognized and their violence is regardedinstead
as "sociopathy." As a result, males with the disorderare far more likely than their female counterparts to be
arrestedand incarcerated.

The 12 murderers in our study were unaware of their psychiatriccondition.
They also had partial or total amnesia for the abusethey had experienced as children. Such is the nature of dissociativeidentity disorder. Contrary to the commonly held assumptionthat individuals facing the consequences of murder
charges willexaggerate their childhood misfortunes, these murderers couldbarely remember anything
about their childhoods. What is more,contrary to the popular belief that probing questions will eitherinstill
false memories or encourage lying, especially in dissociativepatients, of our 12 subjects, not one produced false
memoriesor lied after inquiries regarding maltreatment. On the contrary,our subjects either denied
or minimized their early abusiveexperiences. We had to rely for the most part on objective recordsand
on interviews with family and friends to discover that majorabuse had occurred.

Even if the subjects had been able to provide memories of maltreatmentand even if they had been aware of their diagnosis, becausewe were dealing with two problematic issues—murder
anddissociative identity disorder—it was vital that we documentfrom outside sources as much
objective evidence as possibleof dissociative symptoms and childhood maltreatment. We didthis. In
every case, three or more outside sources providedindependent evidence of subjects' marked changes in voice, demeanor,and behavior, and in 11 cases abuse was also verified objectively.Furthermore, in 10 cases handwriting samples
produced beforethe offenses in question documented changes in writing stylesand signatures. Thus,
the diagnosis of dissociative identitydisorder and the history of abuse did not rest exclusively oreven
primarily on reports obtained from a subject.

The extent to which it was possible in these murder cases toreview
old records, interview families, and obtain objectivedocumentation of symptoms and early abuse was, of course,
unusual.In most cases of dissociative identity disorder, this degreeof verification is not possible.
Nevertheless, our experiencewith these 12 murder cases illustrates that with sensitivity,diligence,
and appropriate resources, corroborative externalevidence of prior dissociative symptoms and of early, extremeabuse in adult patients with dissociative identity disorderis there to be found. We may not always be able
to obtain thisextensive a body of documentation for all of our patients, butwe must try.

FOOTNOTES

Received April 5, 1996; revisions
received March 24 and July7, 1997; accepted July 31, 1997. From the Department of Psychiatry,Division of Child and Adolescent Psychiatry, New YorkUniversitySchool of Medicine. Address reprint requests to Dr.
Lewis, Departmentof Psychiatry, New York University School of Medicine, 550 FirstAvenue/New Bellevue 21 South 14, New York, NY10016.